Radiological evidence of existing or impending compression of the spinal cord, conus medullaris or cauda equina by metastatic disease

Urgent neurosurgical opinion should be considered for patients with symptomatic spinal cord compression, as evidence suggests that in selected patients, outcomes are better with decompressive surgery prior to radiotherapyr

Note

If no previous diagnosis of malignancy, consider obtaining a biopsy of relevant tissue prior to commencing treatment

Treatment with surgery or radiotherapy should be commenced within 24 hours of diagnosis for best functional outcome

Note

The evidence supporting this protocol comes from the 2008 Cochrane Review by George et alr of 6 randomised trials including 544 patients and the Systematic Review by Loblaw et al.r

Efficacy

Radiotherapy is the most widely used treatment in the management of malignant spinal cord compression. The Cochrane review by George et alr of 6 randomised trials (n=544) of which Patchell et alr was the only trial to compare surgery vs RT reported the following outcomes:

The Patchell studyrexcluded patients with multiple levels of spinal cord compression and chemotherapy and radiotherapy sensitive disease. It is important to note that patients with pathological fractures and spinal instability were included in the randomisation, a situation which radiotherapy alone would not be expected to reverse and may have contributed to the poorer ambulatory outcomes in the radiotherapy alone arm. A requirement of the trial was neurosurgical anterior decompression within 24 hours of diagnosis, which may not be achievable in many settings.

Palliative spinal cord radiotherapy for cord compromise may not reverse neurological deficits, but may still be appropriate to improve pain control.

Optimum Dose

Single fraction radiotherapy of 8Gy has been shown to be just as effective as multiple fractions in patients with a poor prognosis. For patients with a good prognosis (the use of surgery and radiotherapy should be considered.r

Bibliography

Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10-15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional outcomes can be achieved with short-course radiotherapy regimens and longer-course radiotherapy regimens. Longer-course radiotherapy is associated with better local control of MESCC than short-course radiotherapy. Patients with a more favorable survival prognosis (expected survival of >/=6 months) should receive longer-course radiotherapy, as they may live long enough to develop a recurrence of MESCC. Patients with an expected survival of <6 months should be considered for short-course radiotherapy. A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy. After primary administration of longer-course radiotherapy, decompressive surgery should be performed if indicated. Alternatively, re-irradiation can be performed using high-precision techniques to reduce the cumulative dose received by the spinal cord. Larger prospective trials are required to better define the appropriate treatment for the individual patient.

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Urgent neurological opinion should be considered for patients with symptomatic spinal cord compression, as evidence suggests that in selected patients outcomes are better with decompressive surgery prior to radiotherapy.

Remove exclusion of no prior high dose RT in treatment field.

Important Additional Information

If no previous diagnosis of malignancy, consider obtaining a biopsy of relevant tissue prior to commencing treatment.

Treatment with surgery or radiotherapy should commence within 24 hours of diagnosis for best functional outcome.

Patients should be commmenced on corticoid steroids (up to 16mg dexamethasone a day in divided doses) as soon as the diagnosis of cord compression is suspected.

Consider referral to palliative care services.

Concurrent treatment

No concurrent cytotoxic treatment is recommended.

Concurrent corticoid steroids given as above.

If patient is receiving cytotoxic chemotherapy, discuss the potentially increased risk of side effects with radiotherapy.

Simulation

If treating upper cervical spine consider positioning with arms by sides using appropriate immobilisation to lower the shoulders and facilitate lateral fields.

Dose prescription

Note: Higher doses than those listed may be considered for patients who are ECOG 0-1 and have a long disease natural history.

Single posterior fields are typically prescribed at a clinically relevant depth as demonstrated on imaging.

AP/PA opposed fields may be prescribed to midplane to achieve appropriate coverage.

For high doses, 3-4 fields may be required with prescription to ICRU reference point.

Consideration should be given to weekend treatment.

Target Volumes

Typically, one vertebrae above and below the level of involvement is included within the radiotherapy field. A GTV may be used to verify adequate coverage of disease.

Image of AP/PA field added showing field based delineation of 1 vertebrae above and below the compression.

Beam arrangement is typically PA or AP/PA except in the upper cervical spine, where opposed lateral fields may be considered to reduce mucosal toxicity.

Efficacy

Protocol based on the Cochrane review by George et al 2008 and the Patchell study 2005.

Efficacy Optimum Dose - include:

Single fraction radiotherapy of 8Gy has been shown to be just as effective as multiple fractions in patients with poor prognosis. For patients with a good prognosis ( the sue of surgery and radiotherapy shoudl be considered. Loblaw 2011.

The information contained in this protocol is based on the highest level of available evidence and consensus of the eviQ reference committee regarding their views of currently accepted approaches to treatment. Any clinician (medical oncologist, haematologist, radiation oncologist, medical physicist, radiation therapist, pharmacist or nurse) seeking to apply or consult this protocol is expected to use independent clinical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use is subject to eviQ’s disclaimer available at www.eviQ.org.au